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Home My WebLink About02-01-12~~ 1505610140 REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 1 0 8 1 5 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY 1 8 2 4 6 4 4 8 1 0 7 0 9 2 0 1 1 0 7 2 4 1 9 5 5 Decedent's Last Name Suffix Decedent's First Name MI O' Br i en Mi chael E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Steven R. Snyder, Esq. 717 241 6070 First line of address R o m i n g e r Second line of address 1 5 5 Sou t h City or Post Office Car l i s l e & A s s o c i a t e s H a n o v e r S t r e e t State ZIP Code P A 1 7 0 1 3 Correspondent's a-mail address: Sflyder~rOnlingerlaW.COm REGISTER O~UILLS USE O~Y C _-_. ~~ ~ ~ ~~ r ~ 1 -, r_. - .y rn x t - ~, ~ ~_-; : ;~ , c 7 ~ ~~ -Ti ~ ~ ~ , EYILED ~";~ --~~ t'z"t .~" ~ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declarati of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI~PE~N NS R FILING RETURN DATE ADDRESS 155 South Hanover Street SIGNATU~tE OFAREF~IRERBi THAN Carlisle RL~ENTATIVE ~ JI Jacksonville PA 17013 DATE FL 32244 1505610140 J ~/ 9390 Grand Falls Drive 1505610140 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: MlChael E. O'Brien 1 8 2 4 6 4 4 8 1 RECAPITULATION 1. Real Estate (Schedule A) ......... ................ .. 1. 2. Stocks and Bonds (Schedule B) .................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4. 5. Cash, Bank De osits and Miscellaneous Personal Pro e p p rty (Schedule E)..... .. 5. 9 2 2 2 . 1 6 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 0 • 0 0 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested ..... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 9 2 2 2 . 1 6 9. Funeral Expenses and Administrative Costs (Schedule H) ............ ...... 9• 5 0 0 6 • 8 4 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ...... 10. 3 3 0 2 • 0 2 11. Total Deductions (total Lines 9 and 10) ......................... ...... 11. 8 3 0 8 . 8 6 12. Net Value of Estate (Line 8 minus Line 11) ...................... ...... 12. 9 1 3. 3 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................ ...... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................ ...... 14. 9 1 3. 3 0 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)X.0 _ 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 9 1 3. 3 0 1s. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 1 g• 19. TAX DUE ....................... ........................ ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 1505610240 0. 0 0 4 1. 1 0 0. 0 0 0. 0 0 41.10 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 11 0815 DECEDENT'S NAME Michael E. O'Brien _ __ STREET ADDRESS -- --- 520 Reno Avenue, Apartment 7 CITY STATE - _ _- ' ZIP New Cumberland PA 17070 Tax Payments and Credits: ~~ Tax Due (Page 2, Line 19) (1) 41.10 2. CreditslPayments A. Prior Payments 8.48 B. Discount Total Credits (A + g) (2) 8.48 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 32.62 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ 0 c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ ^X 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ O 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? ......... ^ ^X 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................. ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ M~S~r. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Michael E. O'Brien 21 11 0815 Include the proceeds of litigation and the date the proceeds were received by the estate, All oropertv iointN-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Inheritance as executor of Estate of Lillian C. O'Brien, checking account from 8,036.16 Members First Federal Credit Union 2. Opening balance for Estate checking account at Orrstown Bank ~ 1,186.00 TOTAL (Also enter on line 5, Recapitulation) ~ $ 8,222.16 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Michael E. O'Brien 21 11 0815 Decedent's debts must be reported on Schedule t. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hoffman-Roth Funeral Home 2,100.94 B ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address 2. 3. City State ZIP Year(s) Commission Paid: Attorney Fees; Rominger & Associates Family Exemption: (If decedent's address is not the same as claimants, attach explanation.) Claimant Street Address 4 5. 6. 7. 8. City State ZIP Relationship of Claimant to Decedent Probate Fees: $128.50 filing fee to open Estate, $15.00 filing fee for Inheritance tax $8.48 Inheritance tax Accountant Fees: Tax Retum Preparer Fees: Cumberland Law Journal, advertise Letters The Sentinel, advertise Letters TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 2, 500.00 151.98 75.00 178.92 REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Michael E. O'Brien 21 11 0815 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. Capital Self Storage, rental space for houshold goods 206.70 2. Verizon Wireless, mobile phone 50.08 3. Robin Gasperetti, Tax Collector, per capita tax 9.80 4. PPL, electric provider 103.73 5. PPL, electric provider 1.96 6. Dirty Dog Hauling, clean apartment and haul trash 1,075.00 7. Todd O'Brien, reimburse for moving household goods 1,259.00 8. Todd O'Brien, partial reimbursement 595.75 TOTAL (Also enter on Line 10, Recapitulation) I $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) Pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE I BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Michael E. O'Brien ~~ „ nQ, ~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Todd M. O'Brien Lineal 100.00 9390 Grand Falls Drive Jacksonville, FL 32244 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: L B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ Ir more space Is needetl, use additional sheets of paper of the same size.